Geriatric Assessment: An Office-Based Approach

 

Family physicians should be proficient in geriatric assessment because, as society ages, older adults will constitute an increasing proportion of patients. Geriatric assessment evaluates medical, social, and environmental factors that influence overall well-being, and addresses functional status, fall risk, medication review, nutrition, vision, hearing, cognition, mood, and toileting. The Medicare Annual Wellness Visit includes the key elements of geriatric assessment performed by family physicians. Comprehensive geriatric assessment can lead to early recognition of problems that impair quality of life by identifying areas for focused intervention, but a rolling geriatric assessment over several visits can also effectively identify subtle or hidden problems. Assessment should be tailored to patient goals of care and life expectancy. By asking patients and families to self-assess risks using precompleted forms, and by using trained office staff to complete validated assessment tools, family physicians can maximize efficiency by focusing on identified problems. Fall risk can be assessed with a single screening question: “Have you fallen in the past year?” The Beers, STOPP (screening tool of older persons' prescriptions), and START (screening tool to alert doctors to right treatment) criteria are helpful resources for reviewing the appropriateness of medications in older adults. Screening for depression is recommended when depression care supports are available; this can be performed with a brief two-item screen, the Patient Health Questionnaire-2. Older adults should be screened for unintentional weight loss and malnutrition. Although rates of hearing loss and vision loss increase with age, there is insufficient evidence to recommend screening in asymptomatic individuals. The U.S. Preventive Services Task Force advises clinicians to assess cognition when there is suspicion of impairment. Urinary incontinence can impair patients' quality of life, and it can be assessed with a two-question screening tool. Immunizations and advance care planning are also important components of the geriatric assessment.

Older adults with complex chronic conditions will be an increasing proportion of family physicians' patient population. In 2015, patients older than 65 years accounted for 31% of all U.S. office visits, and that proportion will grow.1 Since 2013, every day 10,000 baby boomers turn 65 years of age and enter Medicare.2 By 2030, the population older than 65 years will double to 72 million (20% of the total U.S. population).2 Individuals are living longer, with multiple chronic illnesses, making them vulnerable to disability and diminished quality of life. Although 95% of older patients with complex needs have regular access to care, 58% struggle to navigate the system, and 62% are stressed about their ability to afford housing, utilities, or meals.3 Geriatric assessment, which evaluates medical problems; cognitive, affective, and functional abilities; and social and environmental factors, can identify these unrecognized needs to improve the well-being of older adults.

Evidence Base for Comprehensive Geriatric Assessment

Most of the literature supporting geriatric assessment models involves specialized geriatric team-based assessment. Comprehensive geriatric assessment is a systematic evaluation of frail older persons by a team of health professionals and consists of six core components: data gathering, team discussion, development of a treatment plan, and implementation of a treatment plan, with monitoring and revision as needed.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Physicians should screen older patients for a risk of future falls using a single question, “Have you fallen in the past year?” In-depth, multifactorial risk assessment for falls should be reserved for patients who respond affirmatively or those who take longer than 12 seconds to perform a Timed Up and Go Test.

C

10, 1315

Older adults should be screened for depression when appropriate support measures are available to ensure accurate diagnosis, effective treatment, and follow-up.

B

21, 22

There is insufficient evidence to recommend screening for hearing loss in asymptomatic adults older than 50 years. Targeted screening should be performed in those with perceived hearing loss, and cognitive and affective symptoms.

C

28, 30

Targeted screening for cognitive impairment is appropriate for patients with suspected impairment. The Mini-Cog tool is effective in primary care and appropriate for trained staff to

The Authors

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PAUL E. TATUM III, MD, MSPH, CMD, AGSF, FAAHPM, is an associate fellowship director of geriatric medicine, fellowship director of hospice and palliative medicine, and an associate professor in the Department of Family and Community Medicine at the University of Missouri, Columbia....

SHAIDA TALEBREZA, MD, AGSF, FAAHPM, HMDC, is an associate professor of geriatric medicine at the University of Utah School of Medicine in Salt Lake City. She is also the medical director for the Inspiration Hospice in Salt Lake City, and serves as a geriatrician and palliative care specialist for the George E. Wahlen Department of Veterans Affairs Medical Center in Salt Lake City.

JEANETTE S. ROSS, MD, is a clinical associate professor in the Department of Family and Community Medicine and the Department of Medicine at the University of Texas Health Science Center in San Antonio (UTHSCSA). She is also program director of the geriatric medicine fellowship at UTHSCSA, staff physician in the geriatrics and extended care service, and acting associate director of education and evaluation for the San Antonio Geriatric Research, Education and Clinical Center at South Texas Veterans Health Care System.

Address correspondence to Paul E. Tatum III, MD, MSPH, One Hospital Dr., Columbia, MO 65212 (e-mail: tatump@health.missouri.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

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